Julie’s experience of depression

Julie is a 32 year old graphic designer. In January she started feeling low in mood and was finding it difficult to get motivated to go to work. For the first couple of weeks, she put this down to ‘post-Christmas blues’. Over the next few weeks, she began struggling more with motivation and everything seemed like a huge effort. She began having thoughts like “I am stuck in a rut”, “Everyone else is doing better than me”, “I’m going no-where”. Things she previously really enjoyed doing like swimming and seeing her friends were no longer enjoyable. Since everything was such an effort to Julie, and when she did make the effort she didn’t enjoy it, she began doing less and less. Her friends called regularly and invited her out, but she started to refuse these invitations because she no longer enjoyed being out socially and she felt like a burden to her friends. By the end of February, Julie was no longer going out other than for work, she was struggling to get out of bed in the morning and when she was at work, she found it a huge effort and thought everything she produced was “useless”. She began to feel hopeless about the future, her mood became lower and she decided to take two weeks off to “try and sort herself out”. She went to her GP and was prescribed an anti-depressant medication. Three weeks later, nothing had changed and Julie realised she had to do something or she would risk losing her job and her friends.

When I met Julie for assessment in March, she told me how her problems had developed over the previous three months. She said she couldn’t understand why she was feeling this way as she has a great life with lots of friends, a close family and a good job. She said that nothing significant had happened in the past few months to explain the way she is feeling and that she is “just being pathetic”.

Julie completed some questionnaires to assess the severity of her depression and she scored in the moderate range. Cognitive-behaviour therapy has an extensive evidence-base for the treatment of moderate depression and is recommended by the National Institute of Clinical Excellence (NICE) as the treatment of choice. I discussed this approach with Julie and we agreed to meet for 6 sessions in the first instance followed by a review. Julie’s sessions included the following:

1) Understanding how the problem developed and was being maintained:

This is a very important part of therapy as it increases understanding and self-compassion as well as identifying areas that may require attention in therapy. We talked about a number of events that had happened in the last six months of Julie’s life which helped make sense of why she was feeling low, such as the break-up of a relationship, her best friend becoming pregnant and her sister moving away for a promotion at work. Julie learned that while none of these events alone explained her low mood, together they triggered a life review which resulted in her having thoughts that she was stuck and not moving on as others were doing. These thoughts triggered feelings of low mood and lack of motivation. We also spoke about factors that were maintaining the low mood such as not going out, not seeing friends and self-critical thinking. This understanding helped Julie see the importance of the next phase of therapy.

2) Re-establishing previous levels of functioning:

Lack of activity was identified as one of the maintaining factors in Julie’s depression. Research has demonstrated that activities which provide an individual with a sense of pleasure and mastery are most helpful in terms of improving mood. Therefore we spent two sessions thinking about activities that Julie enjoys and finds worthwhile and began working on increasing these in a gradual way that felt manageable to Julie. For example, Julie identified that while she found it difficult being out in a group, she found it easier in a 1:1 situation. Therefore she started to increase her activity levels by meeting a good friend for a coffee and a walk a couple of times a week and gradually built up the frequency of going out over the next few weeks. Julie had always enjoyed swimming and while she was reluctant to start going again, with some information about the benefits of exercise for mental health and a little therapist encouragement, she managed to go. While she didn’t enjoy the first few swims, she got a great sense of achievement from going and over time she enjoyed it more. Engaging in these and other activities resulted in a significant improvement in her mood.

3) Managing self-critical thoughts:

Next we moved onto Julie’s thinking style. Julie was having a lot of self-critical thoughts such as “I am useless”, “No-one wants me around, I am a burden”. These thoughts were having a negative impact on her mood and self-esteem and as they were maintaining her depression, we agreed they needed to be tackled. We spent three sessions working on self-critical thinking and increasing self-compassion. This work focused on learning to identify negative and self-critical thoughts, evaluating the truthfulness of these thoughts and developing more balanced and helpful ways of thinking. Julie realised that she was constantly telling herself off, even for things that were not her fault and that speaking to herself in this way was holding her back instead of moving her on. By developing a more balanced and compassionate way of thinking, she focused on what she was doing well and her mood improved.

4) Review and relapse prevention

At session 6, we had a review and Julie said she was getting a lot from therapy. As there was still work needed on her thinking style, we agreed to 2 more sessions to complete this part of the work and develop a relapse prevention plan. We worked on thinking in session 7 and used session 8 to develop the relapse prevention plan which consisted of identifying skills and strategies she had learned to manage her mood, considering potential triggers in the future and planning how she will manage these. At the end of therapy, Julie completed the same questionnaires and her scores showed that she had minimal depression. Julie was delighted with the outcome of therapy as she not only felt better but also had the skills to manage any future occurrences of low mood.